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Interprofessional Team Development

for Diabetes Care – Discussion Paper

January 2008

Introduction ...........................................................................................................1
Roles and Responsibilities...................................................................................2
Chronic Disease Prevention and Management Diabetes Program – Key
Chronic Disease/Diabetes Program – Key Tasks & Actions .............................4

1. Identifying Patients....................................................................................................4

2. Understanding Patient Needs and Available Resources............................................6

3. Developing Chronic Disease Management Programs ...............................................7

4. Delivering Chronic Disease Management Programs .................................................8

5. Coordinating Chronic Disease Management Programs ...........................................10

6. Measuring Success – Evaluating Chronic Disease Management Programs............11

Appendix A ..........................................................................................................12

Patient Education Specialist – Urban Family Health Team...........................................13

Health Promoter, Family Health Team .........................................................................14

From Wikipedia, the free encyclopedia.........................................................................15

Appendix B ..........................................................................................................16
Document contributed by:

Michelle Murti, Family Medicine Resident

Women’s College Family Health Team

Document created as part of the work of the Diabetes Tool Kit Task Group

The Diabetes Tool Kit Task Group is one of four task groups formed as part of the
project ‘Interprofessional Clinical Program Development for a Network of Family
Health Teams’.

Project Sponsor:

Academic Family Health Team Forum

Department of Family and Community Medicine, University of Toronto

Project Funder:

Primary Health Care and Family Health Teams

Health System Accountability and Performance Division

Ministry of Health and Long Term Care

Defining Roles For Interprofessional Diabetes Teams

The objective of this Task Group is to provide a tool for use by Family Health Teams (FHTs) in
Ontario to aid in developing their own chronic care management programs for type 2 diabetes. The
principles for care provision and support to patients/clients with diabetes by primary care team
practices include being: proactive, consistent, comprehensive and flexible.

Due to the different stages of development of FHTs, as well as the varying resources available, this
tool focuses on enabling individual FHTs and family practice teams to make decisions within their
team based on their organization’s goals, patient needs and staffing capacity.

This document provides FHTs with a resource from which key tasks can be designated to the
participating members of the diabetes team.

The first step is to outline the scope of practice of the various team members. This ensures that all
members are aware of the roles and responsibilities of the different disciplines when creating an
interdisciplinary team. The Ministry of Health and Long Term Care (MOHLTC) has prepared a
guide1 as part of its Family Health Team information series that outlines the roles and responsibilities
of most of the professions. It describes what each Practitioner can do in terms of: Assessment,
Treatment/Management, Education/Advocacy, and Referrals/Collaboration. In addition to the health
professionals listed, we have provided information on other potential team members such as Diabetes
Nurse Educator, Heath Promoter, and Patient Educator Specialist, not described in the MOHLTC
guide. Please see appendix A.

The second step is to develop a diabetes program within the Ministry approved Chronic Disease
Prevention and Management framework.

The MOHLTC has outlined steps for FHTs to develop Chronic Disease Management Programs2. The
Task Group has further refined these functions to describe the necessary components of a diabetes
program, and have outlined the Key Tasks that each team should consider and/or implement.

Each FHT can use this resource to assign the key tasks to members of their diabetes management
team. We have provided a Roles Matrix to assist in this process. Assignment of actions to specific
team members ensures accountability and improves service delivery. The designation of who
completes the Key Tasks can apply uniformly to all patients/clients identified for diabetes
management, or can be adjusted for an individual patient/client. This flexibility takes into account
patient/client preferences for certain care providers as well as complexities of care for certain

Defining Roles For Interprofessional Diabetes Teams

Roles and Responsibilities

Family Health Teams being developed in Ontario include a range of health professionals. Currently
most teams have some combination of the following professionals:

• Family Physicians
• Nurse Practitioners
• Nurses
• Nurse Educators
• Patient Education Specialists
• Dietitians
• Pharmacists
• Social Workers
• Health professional trainees

Some teams also have either full time, part time or preferred access to chiropodists, occupational
therapists, physiotherapists, health promotion specialists, psychiatrists and other consultants.

It is assumed that health professional trainees may perform the same roles as fully certified colleagues
under appropriate supervision.

FHTs creating programs around diabetes management should include one or more professionals who
have the Certified Diabetes Educator status (or have team members working toward this designation).

The MOHLTC document “Family Health Teams Advancing Primary Health Care: Guide to
Interdisciplinary Team Roles and Responsibilities”1 is an important resource. It outlines the regulated
scope of practice of most of the professionals currently working within FHTs. Having an
understanding of what the various members can do under their Regulatory body or Professional
Association allows the team to avoid duplication of services delivered by its members and also
enables insights into the possible extent of services a practitioner may be able to offer. Within teams,
individual members of the practice may have refined their own scope of care delivery based on
expertise, preference and skill set. It is the assumption of this Task Group that these important
discussions will occur within each team and within the context of the design and implementation of
specific programs.

Defining Roles For Interprofessional Diabetes Teams

Chronic Disease Prevention and Management Diabetes Program –

Key Tasks
The MOHLTC document “Family Health Teams Advancing Primary Health Care: Guide to Chronic
Disease Management and Prevention”2 has outlined the necessary steps in developing and
implementing a chronic disease program. The steps are:

• Identifying patients
• Understanding patient needs and available resources
• Developing a chronic disease management program
– Adopting evidence-based guidelines
– Translating guidelines into action
• Delivering a chronic disease management program
– Educating patients
• Coordinating a chronic disease management program
• Measuring success – evaluating chronic disease management programs

The Task Group has refined these steps for development of a diabetes program by identifying Key
Tasks under each section. The Key Tasks are the action statements that the diabetes team must
consider and/or implement when developing their diabetes program. They are based on the
MOHLTC requirements,2,3,4 Guidelines Advisory Committee recommended guidelines5, research on
quality improvement strategies6 and input from the Task Group.

Most of the Key Tasks can be performed by different members of the diabetes team, and it is up to
each FHT to distribute the tasks at their local site. Task assignment can be made for each individual
patient/client, or globally for all patients/clients. We have provided a Role Matrix chart which the
team can use to assign the Tasks to the various members. As some tasks can be performed by
multiple members of the team, there will be some differing approaches from the pilot sites.

Defining Roles For Interprofessional Diabetes Teams

Chronic Disease/Diabetes Program – Key Tasks & Actions

1. Identifying Patients
This first step recognizes that the FHT has a population of patients with diabetes that require a
collaborative and proactive approach to care. In order to create a diabetes program that addresses this
population, all team members must have an understanding of the natural history and co-morbidity of
diabetes and the need for various services over time. The team must also have an understanding of
the application of chronic disease management programs and the necessary organizational changes to
provide this care (e.g., rostering and case management).


 Establish need and buy-in for the creation of a diabetes team

• Team changes include: adding a team member or “shared care”, use of multidisciplinary
teams, expansion or revision of professional roles.6
– Identify members of the team (what disciplines should and can be involved?)
– Identify other key players (e.g., specialists, family members)
– Identify resources available to the team (What local resources do you have available in
your community that you can call upon? DEC? CDE at local pharmacy? Administrative
– Review roles, responsibilities and capabilities of team members. (See above section
Roles and Responsibilities)

 Choose a standardized flow sheet to be used by the team (see Tools section for examples)
• Ensure the flow chart incorporates all of the MOH and CDA4,5 recommended elements
• Ensure all clinicians are familiar with and comfortable using the flowsheet
• Standardize how and when information will be recorded on the flowsheet
• Decide where the flowsheet will be placed
• Decide on who will maintain the flowsheet
• Decide on where new flowsheets can be accessed (hard copies versus electronic copies)

 Develop criteria for identifying patients ‘eligible’ for team-based care

• Eligible patients may include those at risk for diabetes, persons with diabetes or persons at
high-risk for complications, depending on the capacity of the team. Examples of targeting
patients include patients consistently out of their metabolic range, newly diagnosed patients,
socially or medically complex patients.
• Eligible persons may be ‘flagged’ by the physician or NP, for particular case management
approaches and goal setting. Some practices may decide to offer a full range of information
and counselling to all patients diagnosed or at risk of diabetes. The decision around
intensified treatment resources will rest with each FHT.

Defining Roles For Interprofessional Diabetes Teams

 Roster patients within a reminder system

• Electronic tracking system as this becomes possible with the fuller implementation of the
Electronic Health Records
• As interim step, where necessary, develop a manual roster by eliciting help from the practice.
Reception staff may also be able to contribute to the creation of this list.

 Identify a case manager.

• Case management includes “any system for coordinating diagnosis, treatment, or ongoing
patient management by a person or multidisciplinary team in collaboration with or
supplementary to the primary care clinician.” “The most significant changes occur when the
case manager (either a nurse or pharmacist) can make independent medication changes.”6
• The care manager within diabetes team would:
– Be the main point of contact and post diagnosis referral for patients, team members and
external resources (e.g., community services)
– Monitor patient progress/review charts
– Ensure completion and updating of the flowsheets of rostered patients
– Ensure completion of the “must-do” tasks for the Designated Visits (monofilament
testing, random blood sugars, discussion on progress of goals, reinforcement and
discussion of external provider visits – e.g. education session)
– Communicate “next-steps” for care process to the patient
– Identify patients in need of additional services based on information obtained from initial
and follow-up designated visits, from the flow sheet and/or patient discussions; make
referrals as necessary(with the exception of specialist consultations).

Defining Roles For Interprofessional Diabetes Teams

2. Understanding Patient Needs and Available Resources

Once patients are identified as requiring a diabetes management program, it is vital that the team
understands the needs of this population and how to serve them. The team needs to assess the
patient’s overall determinants of health and the resources in place to address them. The team should
use patient-centred goal setting and motivational counselling to educate and empower patients for
self-management. Ongoing advocacy for individuals, communities and healthy public policy are
important facets of family medicine and primary care within communities.


 Initial assessment of patient-centered determinants of health and how these may impact
compliance with care plan and goals

 Initial and ongoing assessment of patient’s stage of change

 Identification and use of community resources

• Compile and keep updated a list of key community partners such as Diabetes Education
Centres, community fitness programs, etc.
• Engagement with community partners for capacity building and seamless care
This will help facilitate the “shared care model”, improve care efficiency and relieve external
stressors/burden on the primary caregivers

 Motivational interviewing for self-management

• Recommended physical activity
• Nutrition
• Smoking cessation
• Maintenance of healthy weight
• Medication usage
• Foot care
• Use of community resources

 Advocate for patient, community, and public policy

Defining Roles For Interprofessional Diabetes Teams

3. Developing Chronic Disease Management Programs

Adopting Evidence-Based Guidelines and Translating Guidelines Into Action

The Guidelines Advisory Committee has provided a summary of the recommended guidelines (see
Evidence section) for diabetes care.

All team members should understand and apply the guidelines relevant to their patient care.
Individual team members need to maintain competency in their designated professions and engage in
self-directed learning. Team-based learning, trainee supervision and research all promote on-going
evaluation and integration of best practices.


 Identify the learning needs of the diabetes team

 Consider developing education committee/sub group to facilitate meeting the learning objectives.
Clinician education includes interventions designed to “promote increased understanding of
principles guiding clinical care or awareness of specific recommendations for a target condition
or patient population. Subcategories of clinician education include conferences or workshops,
distribution of educational materials, and educational outreach visits” such as academic detailing

 Organize regular education activities for the team

• Disseminate relevant educational materials to the team
• Review team member learning objectives regularly
• Promote educational opportunities for trainees
• Liaise with on-going research activities

Defining Roles For Interprofessional Diabetes Teams

4. Delivering Chronic Disease Management Programs

This step is implementing the previous steps into actual practice. These Key Tasks reflect the
service delivery of diabetes care. Team members should be committed to providing productive
interactions between prepared, proactive teams and informed, activated patients/clients.7 There
should also be a commitment to providing accessible, equitable and culturally-relevant diabetes
care. To do this, partnerships with community providers may be necessary.

 Screening of eligible patients

• (See CDA “Screening for type 2 diabetes, IFG and IGT” flow diagram)

 Organize diagnosis of diabetes first visit and triage

• (see Developing the Care Pathway)

 Initial screen for complications of diabetes and co-morbidity

• Cardiovascular complications
• Dyslipidemia
• Hypertension
• Obesity
• Psychological problems
• Retinopathy
• Nephropathy
• Neuropathy
• Erectile dysfunction

 Initial patient education and patient-directed goal setting

• Patient education includes interventions designed to promote increased understanding of a
target condition or to teach specific prevention or treatment strategies, or specific in-person
education (e.g., individual or group sessions with diabetes nurse educator; distribution of
printed or electronic educational materials).6 Initial and ongoing needs-based diabetes
education in a timely manner
– Identify and discuss patient specific barriers; establish goals and care plan accordingly
– Use of glucometer and self-monitored blood glucose (SMBG)
– Review symptoms of hyperglycemia (and hypoglycemia if applicable)
– Review targets for glycemic control (A1C and SMBG)
– Review targets for lipid control
– Review targets for blood pressure control

Defining Roles For Interprofessional Diabetes Teams

– Review targets for physical activity

– Review need for ongoing screening for retinopathy
– Review potential effects of diabetes on kidney function
– Review symptoms and complications of peripheral neuropathy and need for foot
– Provide the patient with a patient tracker to facilitate awareness of “target” values (see

 Nutrition counselling by a registered dietitian or Certified Diabetes Educator

• If no dietician within your practice, consider referral to community resources (see Identifying
Community Partners section)

 Initial treatment of diabetes

• Primary care versus specialty care
• Lifestyle versus medication

 Routine visits and regular monitoring

• Establish a mechanism within your practice to schedule Designated Diabetes Visits
• Establish a patient reminder system (e.g., postcards or telephone calls) to remind patients
about upcoming appointments or important aspects of self-care.
– Use of patient roster to identify need to recall patients for regular appointment
– Use of case manager to identify need to perform elements of regular monitoring
– Decision on what elements of routine visits and flowsheet recording can be done by
different team members

 Identification and management of suboptimal diabetes control and complications

• Adjustment of initial treatment
• Identify need for other team members
• Identify need for external resources (e.g., referral for specialist care)

 Review patient-centered goals

• Need for further education, self-management support
• Need for individually-tailored service delivery (e.g., language resources)
• Review stage of change

 Influenza and pneumococcal immunization

Defining Roles For Interprofessional Diabetes Teams

5. Coordinating Chronic Disease Management Programs

Collaboration “enables the separate and shared knowledge of the different providers to synergistically
enhance the care provided to each patient/client and to improve access to a comprehensive range of
high-quality and effective health care services.”3 The team members should develop working
relationships with each other to develop mutual trust, respect, understanding and support. The case
manager should ensure there is regular, timely and thorough communication amongst the team and
the patient. Each team member is responsible for maintaining the patient record to reflect relevant
and active issues to communicate to the team, while respecting patient confidentiality.


 Horizontal referral between team members (with the exception of referral to specialty care);
external referrals to be coordinated by case manager or physician (as OHIP number may be

 Establish means of regular communication amongst the team

• Via case-manager, EMR, notes on flow sheet, internal email etc.
• Address issues of communication breakdown by implementing a common record for
documentation rather than use of flow char, other notes/tandem documents to record visits,
• Identify and share information around
– the primary goals (associated date) and notes on progress/regression/change of focus as
care is delivered.
– patient barriers that may interfere or impact specific targets (e.g. metastatic cancer,
depression, chronic pain other co-morbid conditions) that may take precedent and impact
care delivery.
– dates of appointments and recommendations from referrals to other providers (e.g. DEC,
endocrinologist etc.). The case manager should follow up and reinforce what was done at
these visits for continuity of care.

 Regular team-building activities and case conferences

• Consider conducting periodic meetings with the team to discuss progress, gaps, shortcomings,
successes and areas for improvement.

Defining Roles For Interprofessional Diabetes Teams

6. Measuring Success – Evaluating Chronic Disease Management Programs

Healthy program management includes developing objectives and evaluating outcomes to continually
strive for improved delivery of care8. The team must be committed to continuous quality
improvement initiatives that evaluate patient, provider and healthcare system outcomes.


 Identify regular intervals for program assessment

 Identify process outcome indicators

• Patient (e.g., A1C levels, quality of life, satisfaction with care)
• Provider (e.g., appropriate screening and treatment)
• Healthcare system (e.g., access to care, use and completeness of flowsheet)

 Review benchmarks for indicators, and revisit objectives

 Solicit regular user (e.g., patient, provider) feedback on program developments

 Foster team champions to continue iterative quality improvement despite changes in team
membership for sustainability

Defining Roles For Interprofessional Diabetes Teams

Appendix A
For descriptions of the roles of other professionals within FHTs, we have ‘borrowed’ job
advertisements from Family Health Team recruitments. There will be differences observed
among FHTs in terms of focus for qualifications and job profile in these areas. These are
intended as examples only.

To provide information on a Certified Diabetes Educator, we have excerpted from a wiki

definition. A person with this certification will be a member of profession such as nursing, or
pharmacy who, after being engaged in diabetes education for a minimum time as required
by the certifying body, can proceed to the certification steps.

Defining Roles For Interprofessional Diabetes Teams

Patient Education Specialist – Urban Family Health Team

Position Profile:

The PES will play a key role in patient education, health promotion, disease prevention and chronic
disease management. As a member of the inter-professional team, the key role is the development of
high quality primary care patient education initiatives geared towards both individual and group
activities. The PES is accountable for the development and implementation of short-term and long-
term strategic education plans that support the goals of the FHT initiative.

The candidate will promote and enhance the delivery of evidence passed primary care services
through promotion of excellence in primary care and the development, implementation and evaluation
of primary care indicators and outcomes that are impacted by educational initiatives.

Qualifications: (shortened list)

1. Baccalaureate degree in a Regulated Health Profession or other related health sciences

2. Formal training in Adult Education required, or in progress (Baccalaureate or Masters
preferred). Masters degree in Education preferred.
3. Member in good standing of their relevant professional organization and/or regulatory body.
4. Minimum 2 years experience in outpatient and/or primary care setting providing education to
a broad range of clients that face many challenges to education – illiteracy, low reading level
and language barriers.
5. Demonstrated competence in the design, delivery and evaluation of educational programs for
patients in a primary health care environment.
6. Demonstrated skills in patient education planning, consultation and facilitation.

Defining Roles For Interprofessional Diabetes Teams

Health Promoter, Family Health Team

(excerpt from ad in media)

Full Time:

We are presently looking for a Health Promoter with a holistic focus on newcomer and immigrant
health to join our Family Health Team. The Health Promoter will provide mental health and
addictions outreach, education, community development and advocacy to newcomers and immigrants
within our catchment area with an emphasis on residents of social housing and people who are
homeless. This is an exciting opportunity to work as a member of an interdisciplinary care team to
develop and provide a diverse and varied service in a community based setting.

The Health Promoter utilizes adult education, community development, research/evaluation and
policy strategies to enhance the mental well being of communities with a broad range of mental
health, emotional health and substance use issues. S/he makes the links between mental health and
substance use problems and trauma, violence, settlement, family or relationship issues, loss, coming
out, and transitioning.


• Education at the bachelor level in social science or health discipline OR equivalent

combination of education and experience
• At least 3 years experience working with people with mental health and/or substance use
• Excellent community outreach and community development skills
• Up-to-date knowledge of the needs of the diverse communities of South East Toronto and
experience developing culture specific resources
• Experience working in interdisciplinary/multidisciplinary teams
• Experience working with people affected by poverty, violence, homelessness, stigma, racism
and/or homophobia/transphobia
• Experience working within an anti-oppressive and trauma informed framework
• Ability to work flexible hours, including some evenings and weekends
• Excellent interpersonal and communication skills
• Preference will be given to applicants able to work in one or more of the following languages
in addition to English:Tamil, Tagalog, Cantonese, Mandarin, Somali, or Vietnamese

Defining Roles For Interprofessional Diabetes Teams

Certified Diabetes Educator

From Wikipedia, the free encyclopedia

Jump to: navigation, search

This article or section is missing citations or needs footnotes.

Using inline citations helps guard against copyright violations and factual inaccuracies. (July 2007)

A Certified diabetes educator (CDE) is a health care professional who is specialized and
certified to teach people with diabetes how to manage their condition.

Typically the CDE is also a nurse or dietitian who has further specialized in diabetes
expertise. Formal education and years of practical experience are required, in addition to
formal examination, before a diabetes educator is certified. In the US, certification is
awarded by the National Certification Board for Diabetes Educators. In Canada, certification
is awarded by the Canadian Diabetes Association.

The CDE is an invaluable asset to those who need to learn the tools and skills necessary to
control their blood sugar and avoid long-term complications due to hyperglycemia. Unlike an
endocrinologist, the CDE can spend as much time with a newly diagnosed person as is
needed both for educational purposes and emotional support.

[edit] References
• American Association of Diabetes Educators

• National Certification Board for Diabetes Educators

• The American Diabetes Association

• The Canadian Diabetes Association

Defining Roles For Interprofessional Diabetes Teams

Appendix B
The tools provided in this section are included as examples only. The task group recognizes
that a broad range of tools exist and others are being developed/adapted by individual
organizations to best suit the needs of their patients.

Defining Roles For Interprofessional Diabetes Teams

Defining Roles For Interprofessional Diabetes Teams

Defining Roles For Interprofessional Diabetes Teams

1 Ministry of Health and Long Term Care. Family Health Teams Advancing Primary Health Care:
Guide to interdisciplinary team roles and responsibilities. 2005

2 Ministry of Health and Long Term Care. Family Health Teams Advancing Primary Health Care:
Guide to chronic disease management and prevention. 2005

3 Ministry of Health and Long Term Care. Family Health Teams Advancing Primary Health Care:
Guide to collaborative team practice. 2005

4 Ministry of Health and Long Term Care. Diabetes management incentive fact sheet, 2006.

5 Canadian Diabetes Association. Clinical practice guidelines for the prevention and management of
diabetes in Canada. Canadian Journal of Diabetes. 2003, 27(suppl 2).

6 Shojania KG, Ranji SR, McDonald KM, Grimshaw JM, Sundaram V, Rushakoff RJ, Owens DK.
Effects of quality improvement strategies for type 2 diabetes on glycemic control: a meta-
regression analysis. JAMA 2006;296:427-439.

7 Wagner EH, Davis C, Schaefer J, Von Korff M, Austin B. A survey of leading chronic disease
management programmes: Are they consistent with the literature? Managed Care Quarterly, 1999.

8 Langley C, Nolan K, Norman C, Provost L. The improvement guide: A practical approach to

improving organizational performance. San Francisco. Josey-Bass Publishers, 1996.